Integrative Medicine or Bait-and Switch?

For a while now, the Huffington Post has been providing a platform for a prominent voice in the alternative veterinary medicine community, Dr. Richard Palmquist. Dr. Palmquist is involved in the American Holistic Veterinary Medical Association (AHVMA), and has had some rather unkind things to say about CAM skeptics in general, and about my criticisms of the AHVMA in particular. It is unfortunate that someone whose ideas are so far outside the mainstream has been given such a prominent pulpit for disseminating misinformation, and that pet owners are unlikely to realize that Dr. Palmquist’s theories do not accurately represent the science of veterinary medicine or the opinions of most veterinarians.

He must be given credit, however, for representing his position skillfully. One element to putting a positive PR spin on unproven or disproven remedies is the technique known as bait-and-switch (though it is more commonly referred to as “integrative medicine”). This involves recommending or using widely accepted conventional therapies based on scientific reasoning and evidence, and then tagging on unproven therapies or pure nonsense treatments as if they were in the same category. In his most recent post, Dr. Palmquist discusses allergies, which in dogs and cats usually manifest as itching and infections of the skin in response to allergens from fleas, food, or environmental sources (such as dust mites, pollens, etc). There is a good deal of sound scientific research on allergies in pets, and the veterinary dermatology community regularly provides summaries of the research in statements on Evidence-Based Allergy Treatment.

Much of Dr. Palmquist’s post is perfectly consistent with a scientific understanding of the cause and treatment of allergies. He discusses antihistamines, corticosteroids, immunotherapy (aka allergy shots), limited antigen diets, and fish oil supplements, all of which are therapies supported by reasonable plausibility and research evidence. In this discussion, of course, he continuously minimizes the benefits and expounds at length on the potential risks, a clear effort to bias the reader against these therapies while ostensibly acknowledging that they have proven efficacy.

In particular, he harps on the notion that antihistamines and steroids “turn off” parts of the immune system. This sounds like a terrible thing, because everyone knows the immune system is necessary to protect us from infectious disease. So are we compromising the defenses of our patients with these drugs? If properly and judiciously used, no. The implication ignores the complexity of immune function and the effects of anti-inflammatory medications, probably deliberately in order to increase the negative associations people may have in their minds with these medicines.

In response to stimuli, such as infectious agents or allergens, cells in the immune system release chemicals, called cytokines, which lead to the classic inflammatory response: redness, swelling, itching or pain, and sometimes systemic effects such as fever or lethargy. Inflammation is not inherently a good thing. In fact, it can be quite harmful. While a mild fever may help fight off an infection, a high fever that causes brain damage is clearly doing more harm than good. And while activation of the immune system in an effort to fight off disease-causing organisms is a good thing, allergies are by definition an inappropriate activation of the system against proteins that are not inherently harmful. They are uncomfortable chronic diseases caused by excessive, unnecessary activity of the immune system. Even worse are auto-immune diseases, like lupus, hemolytic anemia, and so on, are serious, even deadly consequences of inappropriate immune-system activity. So the implication that turning off part of the immune system is a dangerous or unnecessary part of treating diseases that manifest as excessive immune system activity is nonsense. Suppressing excessive inflammation is exactly what is needed to treat the discomfort or even serious harm these diseases can cause.

It is possible, of course, to increase a patient’s susceptibility to disease with excessive or prolonged use of anti-inflammatories, and undoubtedly some doctors do not use these drugs judiciously. But anything in medicine that has a benefit has a potential risk, and it is disingenuous of Dr. Palmquist to focus primarily on the risks of conventional therapies and the unproven but assumed benefits of alternative methods regardless of the state of the evidence.

Of course, the agenda behind this damning with faint praise of conventional treatments is to build a case for the alternative treatments with which he concludes his article. He first includes limited antigen diets in his list of alternative treatments, though it is a widely accepted conventional therapy, probably because of the mistaken notion that any treatment that is not a drug must be a form of alternative medicine. He also includes fish oils, which are another treatment widely used in conventional medicine, though with only limited supportive evidence.

His descriptions of herbs and supplements, homeopathy and homotoxicology, and other such alternative therapies fairly glow with praise: “can be amazing,” “allergic responses can vanish entirely,” etc. And with the sole exception of high-dose Vitamin C supplementation, no potential risks or unwanted effects are mentioned for any of these treatments.

Dr. Palmquist does state that, “The scientific evidence varies for these methods,” and he supports this statement by reference to the summary of evidence-based allergy treatment I referred to above. However, with the exception of diets and fish oils (neither truly alternative) and phytopica (which Dr. Palmquist doesn’t mention), this review does not provide any evidence in favor of alternative therapies, and in fact it mentions almost none of those he recommends. There is no legitimate scientific evidence to support the utility of acupuncture, Traditional Chinese Medicine theory, homeopathy, homotoxicology, glandular extracts, or digestive enzyme supplementation in the treatment of pet allergies. And most of the herbs and supplements he recommends have little to no evidence to support veterinary allergy use. And yet he discusses these therapies as if they were as effective, and certainly safer, than the proven conventional therapies he so lukewarmly discussed at the beginning of the article.

No question this is a slick bit of propaganda designed to cast doubt on the safety of conventional therapies and to guide readers towards unproven or outright useless alternatives that are presented as if they were legitimate, accepted therapies of proven safety and efficacy. There is an impressive list of supporting references, though many of them are either books written by other proponents of alternative therapies, or articles which, like the dermatology task force review, don’t actually support the safety and efficacy of the alternative therapies being promoted. Some are legitimate studies investigating the safety or efficacy of conventional treatments, but the purpose is clearly not to review the available treatments fairly but to build a public relations case for alternative and against conventional science-based allergy treatments. Though I’m sure Dr. Palmquist feels this is for the greater good, since he is a true believer in the therapies he promotes, in reality such misinformation presented as if it were established fact and biased towards the unproven is not truly in the best interests of our patients or clients.

10 Responses to Integrative Medicine or Bait-and Switch?

Palmquist is certainly good at making even the most ridiculous “alternatives” sound sciency. I wonder how much cortisol is in those glandular extracts he uses?
One thing that bothers me about his post and the evidence-based discussions as well is the high incidence of allergies in certain breeds. Veterinarians of all stripes, and particularly the large veterinary organizations do not seem to want to lay any responsibility on the breeding practices (read; inbreeding) enforced by the AKC and other kennel clubs and basically give tacit or even active support to breeders who perpetuate all sorts of health problems, including allergies. Of course, most clients choose a breed based on other considerations and worry about health issues after buying the puppy instead of before.
Anyway, I find it interesting that people like Palmquist ignore this aspect of pet health at least as much as everyone else does.

The more I see of these blogging alt vets, the more I see a common theme that pet owners don’t really care about the lack of evidence. In my opinion, that’s equally as scary as the woo-meisters’ propaganda.

Is there any evidence that honey is effective? And if so, isn’t all honey organic in some form? (let’s just skip the term organic, in terms of effectiveness)

Jersey suffers from “summer allergies” and if she doesn’t get steroids, she will literally scratch holes into her hide. One of the vets at the clinic scammed me into buying a shampoo that would block the allergens from irritating her skin. I thought that since it is being recommended by a vet, it must be good, right? It was the biggest waste of 30 dollars that I ever spent!

One word of advice that I’d like to give to all the vets out there is to cut down on the dosage! I suffer from Lupus and very occasionally I get a flare-up. For a 160LB woman, my doctors give me a dosage of 20mg of Prednisone to calm the flare down. Jersey is 45LB Vizsla and the vet prescibed the exact same dosage! There was a lot of midnite peeing in the kitchen until I cut the dosage down to 5mg. For the past 5 years, I’ve been giving her 5mg a day until the frost comes, and she’s fine

Thanks for the comment! The issue of dosage is an interesting one. In humans (except for childrenor the significantly obese) almost all drug doses are the same for everybody. And many of these doses were originally based on the hypothetical “average” 70kg man (most studies were done on men until the 70s). This always amazes me as a vet since we routinely calculate drug dosages on a milligram per kilogram (mg/kg) basis. Of course, there is a much wider range of body sizes in my patients (from the 50g mouse to the 75kg giant breed dog, and I don’t even see “large animals”) than among human patients. And if we are truly scientific in our calculations, we should adjust the dose to match lean body mass, since fat doesn’t contribute much to the metabolims of many drugs (though this gets even more complicated since it can influence the distribution of a drug throughout the body).

Anyway, my point is that a careful vet should individualize the drug dosage as much as possible to the patient, within the limits of available forms of the drug. This too is less simple than it sounds though, because there are no manufacturers of veterinary versions of most drugs. So I have to make due with whatever size tablets or concentration of injectable drug is made for humans, which is usually not the optimal choice for my patients.

Prednisone most commonly comes in 5mg and 20mg tablets (though 1mg tablets are available, and we often make our own liquid formulations, which may or may not be as effective as the original tablet formulation since no one is supporting research into that issue). Doses for inflammatory conditions (such as allergies) are about 0.5-1.0 mg/kg per day. And because steroids given to a patient decrease their own production of steroids, we typically wean them off gradually rather than stopping them suddenly.

For Jersey, that would mean a dose between 10-20mg per day to start off, and then a stepwise decrease over time. There is no one right protocol that research shows to be the best, so different doctors do things a little differently. And how severe the symptoms are, how often the dog has been treated in the past, how they have responded in terms of both benefits and side-effects, what other conditions and drugs that are involved, and so on are all factors. In your case, especially, the duration of therapy is a big issue. 5 years of daily steroid treatment is a real concern, and every possible effort should (hopefully) have been made to avoid or minimize the need for that, since no dosage is going to be reliably free of side effects over that length of time. It’s a good thing you are able to at least stop during the cold season. It would be even better if you could find a way to dose only every other day, even if the dose itself needed to be a bit higher.

Anyway, what is not, unfortunately, a useful guideline to the right dose for a dog with allergies is the dose that a person uses for an autoimmune condition like Lupus. There are many difference between your situation and Jerseys besides body size, most importantly the disease and the species (humans are generally more sensitive to steroid side effects than dogs, which in turn are far more sensitive than cats, and so on).

And finally, there is the vast array of factors we know nothing about that make one individual different from another. I have seen dogs Jersey’s size that don’t respond at all to 20mg doses daily and others the same size that respond great to 5mg every 3 days! So contrary to the propoganda of many alternative medicine advocates, vets interested in practicing science-based have to juggle a lot of variables to tailor their therapies to the needs and circumstances of each individual patient in a holistic way. The bottom line is to give as little as possible and still get the desired effect, and it’s a lot of work to determine how much that is for each patient. Unfortunately, some vets don’t make the effort to do this, and it sounds like you may have run across one who practices a less sophisticated “cookbook” style. Or perhaps the problem was one of communication. In any case, Jersey is lucky to have an owner who thinks about ways to minimize the downside to even a necessary medication.

My vet was an “old school’ cranky vet that dismissed my medication concerns since I’m not a vet. I went for the lower dosage since I personally have experience with steroids in my body and know that long term usage is not a good thing. I do the 10mg for two days to start and then 5mg maintenance until the frost comes. Once the frost hits, I give her a week of one whole pill, half pill alternation. Then a week of half pill, no pill alternation. Things seem to be okay and this past summer she and a blood panel done, which turned out fine.

I know that you cannot specifically recommend allergy medications without actually seeing my dog BUT are there non-steriodal allergy meds available for dogs that suffer from “summer allergies” that I could discuss with my vet?

Overall, there is some evidence that ongoing use of fish oils reduce the need for steroids, though they don’t seem to help with acute flareups. Antihistamines don’t appear very helpful, but they are quite safe and possibly might benefit a subset of dogs. Topical steroids and bathing can also reduce the need for systemic medications. If there is a seasonal component and the symptoms are severe, there is a good chance the dog would benefit from allergy shots, if you can find a local vet who can do this, or even better a veterinary dermatologist.